Acumen and Grameen Foundation study poverty rates and impact of Ziqitza Health Care Limited

We live in a country where pizza arrives at our doorsteps faster than ambulances.

Mumbai and other cities in India lack reliable ambulance or emergency medical response services. To get to the hospital, people use auto rickshaws, private cars or van ‘ambulances’ that have no medical equipment or trained technicians. More often than not these ambulances function as hearses. 

Acumen, a leading social impact investor addressing poverty across Africa and South Asia, together with Grameen Foundation India, recently partnered to better understand caller poverty levels for Ziqitza Health Care Limited, an Acumen investee providing emergency ambulance services in India. The study was funded by the Aspen Network for Development Entrepreneurs (ANDE).

Acumen

Acumen is changing the way the world tackles poverty by investing in companies, leaders and ideas. They invest patient capital in business models that deliver critical goods and services to the world’s poor, improving the lives of millions. Since 2001, Acumen has invested more than $88 million in 82 companies across South Asia and Africa. They are also working to build a global community of emerging leaders that believe in creating a more inclusive world through the tools of both business and philanthropy. 

Grameen Foundation

Grameen Foundation is a global non-profit organization that helps the world’s poorest people achieve their full potential by providing access to essential financial services and information on health and agriculture that can transform their lives.

Founded in 1997, it delivers solutions that respond to the needs of the poor, as well as tools that help poverty-focused organizations become more effective. It focuses on initiatives that can achieve widespread impact and uses an open-source approach that makes it easy for other organizations to adopt them broadly. Nobel Laureate Dr. Muhammad Yunus, Founder of Grameen Bank and the Grameen family of companies, is an inaugural member of its Board of Directors, and now serves as Director Emeritus.

Grameen Foundation is headquartered in Washington, D.C., with offices in the U.S., Asia, Africa and Latin America and the Caribbean. Grameen Foundation India is a wholly-owned subsidiary of Grameen Foundation.

Ziqitza Health Care Limited

Ziqitza Health Care Limited (ZHL) was founded in 2005 by a group of young professionals who witnessed the disparity between emergency services in India and the U.S. ZHL operates state-of-the-art 24/7 call centers with ambulance tracking systems, and equips ambulances with personnel trained in basic and advanced life support. ZHL’s training programs are certified by the American Heart Association and New York Presbyterian Hospital.

The company has grown quickly. ZHL operates more than 980 ambulances across five states in India. The company has served over 2 million people since 2005. To date ZHL has been awarded 80 million USD in government contracts to provide free or subsidized service in several states.

The company also conducts free health check up camps for local communities.

In November 2008, ZHL was the first ambulance service to arrive at the Taj and Trident Hotels during the Mumbai terrorist attacks. ZHL was also the first to reach the scene of the July 2011 bomb blasts in Mumbai at Zaveri Bazaar, Opera House, and Dadar[u1] , saving 11 lives.

In Mumbai, ZHL uses a sliding price scale that depends on a customer’s ability to pay – the fee is determined by the hospital type selected by the patient. All accident victims, disaster victims, and unaccompanied victims are transported free of charge. In other locations, calls are subsidized by the government and in some cases patients also pay a small fee.                

Startling revelations from the study

The results show that Ziqitza is overwhelmingly serving low income customers in Punjab and Odisha, the two states studied. On average, 76% of Ziqitza’s callers in those states fall under the $2.50 a day poverty line.

The study used Grameen Foundation’s Progress Out of Poverty Index® (PPI®), a simple 10-question, country-specific poverty measurement tool. The study leveraged existing company operations -- in this case, customer service follow-up calls Ziqitza conducts with a percentage of the over half-million people who use the ambulance service each year.

“This is the first time we have ever known for certain that we are meeting our social mission. It’s reaffirming for us, and the state governments that support the service,” said Sweta Mangal, Ziqitza’s CEO. “These findings help us deliver our service better to customers who need it most and will be helpful in garnering continued support of marketing initiatives and public-private partnerships to serve the poor.”

Serving customers and gaining insights

Ziqitza’s call center operators completed 1,000 customer insight calls using the PPI across Punjab and Orissa, where Ziqitza has several hundred ambulances in operation. In both states, Ziqitza operates through public-private partnerships with state governments that allow emergency medical transportation to be offered free of charge. Five percent of those responses were then validated through in-person interviews to test the accuracy of the results collected by phone.

This approach to gathering accurate data on customer poverty levels sidesteps what is an often burdensome process of sending surveyors into the field to collect income data. These new efforts are part of Acumen’s Lean Data Initiative, an effort to experiment with how to collect impact data more efficiently using different kinds of technology.

The survey report also makes recommendations for Ziqitza and state governments to strengthen their outreach to the poor. The surveyed group was found to be poorer than state averages across the regions we studied except rural Orissa where the population the company is serving is about 10% less poor than the regional average. There, Ziqitza is in the process of expanding its ambulances to reach the poorest areas.

The data also presented important insights about the gender of Ziqitza’s customers. Two-thirds of those surveyed in the random sample were women and for Punjab, poverty levels of female patients were significantly higher than that of their male counterparts. In the same vein, of the total medical complaints registered, 43 percent of cases were pregnancy-related or related to maternal and child health. Coordination efforts between Ziqitza and government schemes that support maternal and child health are the likely contributor to poorer women accessing Ziqitza’s services in higher numbers, demonstrating the potential for impact when successful partnerships are forged among several public and private players.

“Working on this project has been very exciting for us at Grameen Foundation as we were able to test a new methodology for administering PPI questions to clients. We are glad to see socially conscious investors like Acumen and their investees endorse poverty measurement and apply resultant data to their strategy. With our constant endeavour to build a user friendly and statistically accurate tool, reports like this help trigger a larger dialogue around the importance of client level insights and its application for sound business decisions,” said Devahuti Choudhury, Program Manager, Social Performance from Grameen Foundation, India.

Scaling up from nine to 1250 ambulances

Only a few years ago, ambulances in Indian cities were perceived by many as hearses due to a lack of quality standards, and were rarely available in rural areas. Ziqitza began with just nine ambulances at the time of its investment in 2008, and now operates more than 1250 ambulances across India. Since then, it has served more than 3.2 million people.

“These types of insights are invaluable if we are serious about building sustainable and scalable businesses that serve the poor,” said Ajit Mahadevan, Acumen India Director. “Acumen is fully committed to bringing to the forefront the best approaches to impact measurement and integrating these types of learnings into our overall investment process.”

You can also find more details about this study here.